Date Date Surname: ..................................

NHI: ....................
Vital Signs Time (24 hour)
EWS
Time (24 hour)
First Names: . . ..........................................................
> 35 MET > 35
D ate of Bir th: ......... / . . ...... / . . ....... Sex: . . ....................
25-35 3 25-35
Respiratory Rate 21-24 2 21-24 PL ACE PATIENT ID HERE
(breaths/min)
12-20 0 12-20

Wellington Adult Vital Signs Chart

9-11 1 9-11
write value in box
5-8 3 5-8
<5 MET <5
Supplemental O2 write value L/min 2 L/min Medical Staff Modification to Early Warning Score (EWS) Triggers
≥ 96 0 ≥ 96
O2 Saturation (%) 94-95 1 94-95 The EWS can be changed to prevent chronic disease incorrectly triggering escalation.
write value in box 92-93 2 92-93
≤ 91 3 ≤ 91 This can only be authorised by a Consultant or Registrar and should be regularly
≥ 39s 2 ≥ 39s reviewed by the primary team. Ignore any modification that is not signed & dated.
Temperature 38s 1 38s
( C)
o
37s 37s
Accepted Values & Date Doctors name,
Vital Sign
36s
0
36s Modified EWS & time designation & contact details
mark with X
35s 1 35s / /
write value if off scale
≤ 34s 2 ≤ 34s :
Write ≥ 220 3 Write ≥ 220 / /
210s 210s :
200s 200s / /

190s 190s :
Blood Pressure / /
180s 180s
(mmHg) :
170s 170s
/ /
score systolic 160s 0 160s NOT FOR CPR NOT FOR MET
value only :
150s 150s
All limitations must be documented in the patient’s clinical record.
140s 140s
130s 130s Mandatory Early Warning Score Escalation Pathway
120s 120s
110s 110s Total Early Warning Score Mandatory Action
100s 1 100s EWS 1-5 ▪▪ Manage pain, fever or distress
90s 2 90s or any vital sign in yellow zone ▪▪ Increase frequency of vital sign monitoring
80s 80s
3 EWS 6-7
70s 70s or any vital sign in ▪▪ Inform nurse in charge
60s 60s orange zone House officer review ▪▪ Refer to Patient At Risk
MET
50s 50s within 60 minutes (PAR) nurse #6785
Write ≥ 140 MET Write ≥ 140
Acute illness or unstable ▪▪ Increase frequency
chronic disease of vital signs
130s 3 130s
EWS 8-9 ▪▪ Document plan including
120s 120s Registrar review
2
or any vital sign in red zone intervention, escalation
110s 110s within 20 minutes &
& review timeframe
Heart Rate 100s 100s Likely to deteriorate rapidly suggest ICU referral
1
(bpm) 90s 90s
EWS 10+ ▪▪ Dial 777
Capital Docs ID: 1.102513 | Issue date: August 2015 | Review date: August 2019

80s 80s or any vital sign in blue zone ▪▪ State ‘Medical Emergency Team’
mark with X 70s 70s
0
Immediately life threatening & give your location
60s 60s ▪▪ Support Airway, Breathing & Circulation
50s 50s critical illness
40s 2 40s
30s MET 30s CALL 777 FOR ANY PATIENT YOU ARE WORRIED ABOUT
Alert 0 Alert REGARDLESS OF VITAL SIGNS OR EWS
Level of Consciousness Voice / Pain Voice / Pain
3
Unresponsive MET Unresponsive A full set of vital signs with corresponding EWS must be taken & calculated each time
at the frequency stated in the ‘Essential Vital Sign Measurement - Adult Inpatients’
EARLY WARNING SCORE TOTAL EWS TOTAL
protocol. If there is no timely response to your request for review,
escalate to the next coloured zone
write score Move Move
Pain (0-10) Rest Each vital sign is scored according to the coloured zone it falls within (see key below)
Rest
> 100mls / 4h > 100mls / 4h Any patient receiving supplemental oxygen automatically scores 2, regardless of rate
Urine Catheter < 100mls / 4h < 100mls / 4h
Output Early Warning Score Colour Key
PU last 8h PU last 8h
No catheter
Not PU last 8h Not PU last 8h
0 1 2 3 MET: MEDICAL EMERGENCY TEAM